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•Determining outbreak illness burden and trajectory by serotype can guide prevention.•Chicken: Enteritidis, Infantis, Blockley were high burden, increased trajectory.•Turkey: Enteritidis, Reading were high burden, increased trajectory.•Beef: Newport, Dublin were high burden, increased trajectory.•High burden, increased trajectory serotypes warrant intensified prevention action.

Foodborne botulism is a rapidly progressive potentially fatal paralyzing illness caused by the consumption of botulinum neurotoxin, which is most commonly produced by Clostridium botulinum.Refrigeration is the primary barrier to botulinum neurotoxin production in many processed foods. C. botulinumtoxin production has occurred and caused botulism in the United States when foods that were not processed to destroy spores of C. botulinumwere stored in an anaerobic environment and not properly refrigerated. We identified 37 cases, including 4 deaths, that occurred during 1994–2021 in the United States from 13 events associated with inadequate refrigeration of commercially produced products. In 11 events, the patient stored the product unrefrigerated at home; in 2 events, a product was kept unrefrigerated at the store before the consumer purchased it. In three events, refrigeration instructions were inadequate or not easily accessible (one label printed on outer but not inner packaging, one label not clearly visible, and one label was not in English). The number of people affected per event ranged from 1 to 16. Using enhanced cost estimates for foodborne botulism cases from a published economic model, these events were estimated to cost >$79M. Potential solutions to this recurring problem include the addition of a secondary barrier, such as an acidifier, to prevent botulinum toxin production, and better labeling to convey risks of refrigerated foods that have not been processed to destroy spores of C. botulinumand to decrease the occurrence of improper storage and handling.

A single injection of carbetocin appears to be more effective in preventing post-partum bleeding than oxytocin in women who have a cesarean section. Post-partum bleeding often occurs because the uterus is weak, a condition called uterine atony.

This multiagency report developed by the Interagency Collaboration for Genomics for Food and Feed Safety provides an overview of the use of and transition to whole genome sequencing (WGS) technology for detection and characterization of pathogens transmitted commonly by food and for identification of their sources. We describe foodborne pathogen analysis, investigation, and harmonization efforts among the following federal agencies: National Institutes of Health; Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) and U.S. Food and Drug Administration (FDA); and the U.S. Department of Agriculture, Food Safety and Inspection Service, Agricultural Research Service, and Animal and Plant Health Inspection Service. We describe single nucleotide polymorphism, core-genome, and whole genome multilocus sequence typing data analysis methods as used in the PulseNet (CDC) and GenomeTrakr (FDA) networks, underscoring the complementary nature of the results for linking genetically related foodborne pathogens during outbreak investigations while allowing flexibility to meet the specific needs of Interagency Collaboration partners. We highlight how we apply WGS to pathogen characterization (virulence and antimicrobial resistance profiles) and source attribution efforts and increase transparency by making the sequences and other data publicly available through the National Center for Biotechnology Information. We also highlight the impact of current trends in the use of culture-independent diagnostic tests for human diagnostic testing on analytical approaches related to food safety and what is next for the use of WGS in the area of food safety.

Background: Escherichia coli O157:H7 is increasingly recognized as a cause of bacterial diarrhea in the United States, but the frequency of its isolation and the clinical and epidemiologic features of E. coli O157:H7 infection in a large, geographically diverse population of patients have not been well described. Objective: To determine the frequency of isolation of E. coli O157:H7 relative to that of other bacterial enteric pathogens in a nationwide sample of patients and to identify the clinical and epidemiologic features of E. coli O157:H7 infection. Design: Population prevalence study from October 1990 to October 1992. Setting: 10 U.S. hospitals. Patients: Both inpatients and outpatients who had stool samples submitted to 1 of 10 laboratories for routine pathogen identification. Measurements: Clinical, epidemiologic, and laboratory information was collected for infected and uninfected patients. Isolates of E. coli O157:H7 were tested for production of Shiga toxin. Patient charts were then reviewed. Results: Escherichia coli O157:H7 was isolated from 118 (0.39%) of the 30 463 fecal specimens tested. The proportion of fecal specimens with isolates was higher at northern sites (0.57%) than at southern sites (O.13%) (P [is less than] 0.001). Escherichia coli O157:H7 was more likely to be isolated from visibly bloody stool specimens than from specimens without visible blood (odds ratio [OR], 59.2 [95% CI, 36.6 to 96.0]) and was the pathogen most commonly isolated from visibly bloody stool specimens that yielded a bacterial enteric pathogen (39% of such specimens). The highest age-specific isolation proportions from fecal specimens for E. coli O157:H7 were in patients 5 to 9 years of age (0.90%) and 50 to 59 years of age (0.89%). Clinical features independently associated with E. coli O157:H7 infection compared with the other enteric pathogens included a history of bloody diarrhea (OR,18.6 [CI, 7.4 to 48.6]), visibly bloody stool specimens (OR, 8.1 [CI, 3.6to 18.3]), no reported fever (OR, 8.3 [CI, 1.6 to 50.0]), leukocyte count greater than 10 x [10.sup.9]/L (OR, 4.0 [CI, 1.7 to 9.5]), and abdominal tenderness on physical examination (OR, 2.9 [CI, 1.2 to 7.2]). Conclusions: In some geographic areas and some age groups, isolation proportions from fecal specimens for E. coli O157:H7 surpassed those of other common enteric pathogens. One third of isolates of this organism came from nonbloody specimens. Because person-to-person transmission of E. coli O157:H7 is not uncommon and infection with this organism may cause severe disease, stool specimens from all patients with a history of acute bloody diarrhea should be cultured for E. coli O157:H7., Physicians should have all stool samples from patients with bloody diarrhea tested for Escherichia (E.) coli strain O157:H7. Researchers tested 30,463 stool specimens taken at 10 US hospitals during a two-year period. Overall, 118 specimens tested positive for E. coli O157:H7, which was first identified in 1982. The bacterium was much more likely to be isolated from bloody stool samples than non-bloody ones. In fact, it accounted for 39% of all samples in which bloody diarrhea could be traced to a microorganism. It was most common in children aged 5 to 9 and people between 50 and 59.

Background: Although botulism is rare, recognition of a possible case of this illness represents a public health emergency. To prevent more cases, prompt investigation must be done to determine whether illness is linked to a commercial product or restaurant. Botulism can masquerade as other illnesses, and seemingly unlikely foods can harbor botulinum toxin. Objective: To confirm the diagnosis and determine the cause and extent of an outbreak of botulism associated with food served at a delicatessen. Design: Retrospective cohort study of patrons of the delicatessen; laboratory analysis of food, serum samples, and stool samples; and traceback of implicated food. Setting: Community in Georgia. Participants: Patrons of the delicatessen. Main Outcome Measures: Botulinum toxin in food, serum, or stool and Clostridium botulinum in food and stools. Results: 8 of 52 patrons (15%) met the case definition for botulism. In 4 of the 8 patrons, an illness other than botulism was initially diagnosed. Five of the 8 were hospitalized, and 1 died. Stool cultures from 4 patrons yielded type A C botulinum, and two serum samples contained botulinum toxin. All ill persons ate food from the delicatessen on 1 October 1993. Of the 22 persons who ate at the delicatessen that day, all 8 ill persons but none of the 14 well persons ate a potato stuffed with meat and cheese sauce. An open can of cheese sauce contained type A botulinum toxin and yielded C botulinum on culture. Cheese sauce experimentally inoculated with C botulinum spores became toxic after 8 days at a temperature of 22 [degrees]C (room temperature). Conclusions: A commercial, canned cheese caused a botulism outbreak. This product readily becomes toxic when contaminated by C botulinum spores and left at room temperature. Mild botulism caused by unusual vehicles may be misdiagnosed. Botulism should be included in the differential diagnosis of persons with signs or symptoms of acute cranial nerve dysfunction., Botulism should be considered as a possibility in patients presenting with signs or symptoms of sudden onset neurologic dysfunction even if the patient has not eaten a high-risk food. Researchers traced an outbreak of botulism to a commercially prepared cheese sauce served to eight people at a delicatessen. Half the patients were initially misdiagnosed, and one died. It is believed that the unrefrigerated cheese sauce became contaminated by spores from potatoes containing Clostridium botulinum, which is common in soil. The sauce's consistency allowed the low levels of oxygen that permitted the organism to grow.

(Shefer AM, Koo D, Werner SB, et al: A cluster of Escherichia coli 0157:H7 infections with the hemolytic-uremic syndrome and death in California--A mandate for improved surveillance. West J Med [...], In mid-January 1993, an outbreak of Escherichia coli 0157:H7 infections associated with eating hamburger patties at a fast-food restaurant chain (chain A) was reported in Washington State. From mid-December to mid-January, 9 cases of E coli 0157:H7-associated bloody diarrhea and the hemolytic-uremic syndrome had been reported in San Diego County, California. A total of 34 persons had bloody diarrhea, the hemolytic-uremic syndrome, or E coli 0157:H7 organisms isolated from stool during the period November 15, 1992, through January 31, 1993. Organisms of E coli 0157:H7 identified from 6 persons were indistinguishable from those of the Washington outbreak strain. Illness was associated with eating at chain A restaurants in San Diego (odds ratio, 13; 95% confidence interval, 1.7, 99) and with eating regular-sized hamburgers (odds ratio, undefined; lower-limit 95% confidence interval, 1.3). Improved surveillance by mandating laboratory- and physician-based reporting of cases of E coli 0157:H7 infection and the hemolytic-uremic syndrome might have alerted health officials to this outbreak sooner, which could have resulted in earlier investigation and the institution of measures to prevent more cases.

An infection with a spherical organism called Cyclospora may be responsible for unexplained and recurring cases of watery diarrhea. Researchers examined the medical records of 21 hospital employees who were part of a diarrhea outbreak in Chicago. Routine stool sample tests were negative. However, microscopic testing of 10 stool samples revealed the presence of small spherical organisms confirmed by the Centers for Disease Control to be Cyclospora. Most of the patients reported drinking the tap water in the physician's dormitory following a pump failure in the building. Water tests did not reveal the presence of Cyclospora in the water system. Patients had watery diarrhea for an average of 5 days with the illness recurring in many patients over a period of weeks. Patients also reported symptoms of low-grade fever (48%), stomach cramping (76%), vomiting (24%), reduced appetite (48%), and body aches (52%).

High levels of interferon gamma may inhibit fertilization and cause premature failure of the ovaries in women undergoing in vitro fertilization. Researchers working with women undergoing in vitro fertilization conducted cell analysis of granulosa cell progesterone, estrone, and estradiol in the luteal phase of the menstrual cycle, both in the presence and absence of white blood cells. Interferon gamma inhibited the production of granulosa cell progesterone, estrone, and estradiol. It regulated the production of steroids from the ovaries during the luteal phase of the menstrual cycle. White blood cells may inhibit the response of granulosa cell progesterone to human chorionic gonadotropin.

An outbreak of infections caused by Escherichia coli O157:H7 in a rural town in Missouri may have been caused by contamination of the municipal water supply after two water mains ruptured. Among 243 patients with symptoms of an Escherichia coli infection, 86 developed bloody diarrhea, 32 were hospitalized, two developed severe kidney failure and four died. Escherichia coli O157:H7 was grown in the laboratory from 21 stool specimens. Patients drank an average of eight cups of municipal water during the seven days before becoming ill, compared to an average of six cups among town residents who did not become ill. Individuals who drank water from the municipal water supply were almost 20 times more likely to develop bloody diarrhea than those who drank water from a private well. The number of infections decreased after the town's water supply was chlorinated and residents began boiling municipal water before drinking it.

Outbreaks of food poisoning caused by Salmonella enteritidis have become more common in recent years, and eggs are often the source of the infection. In the past, cracked eggs were the source of the salmonella, but recent cases have apparently been transmitted by intact eggs. A salmonella epidemic in Tennessee provided convincing evidence for intact egg transmission of salmonella. Confirmed or probable cases of salmonellosis were documented in 81 patrons of a Knoxville, Tennessee, restaurant, all of whom had eaten at the restaurant on April 8, 1989, and nearly all of whom recalled eating a meal served with either hollandaise or bernaise sauce. The hollandaise sauce had been prepared that evening using two dozen intact eggs, with butter and lemon juice, and then heated briefly. The bernaise sauce was made from the hollandaise sauce with some wine and spices added. The restaurant met local health department standards for cleanliness. The eggs were traced to a farm in Illinois. The chickens on that farm tested positive for a strain of salmonella that was indistinguishable from that cultured from the victims of food poisoning. Eleven of the victims required hospitalization for their symptoms; unlike other salmonella outbreaks of recent years, none died. Prevention of salmonellosis will require destruction of flocks infected with the bacterium, proper cooking of eggs, and may require the use of pasteurized egg products, rather than fresh eggs. (Consumer Summary produced by Reliance Medical Information, Inc.)

The article presents step-by-step process for making sgraffito decoration.

Guillain-Barré syndrome (GBS) is sometimes preceded by Campylobacterinfection. We estimated the cumulative incidence of Campylobacter-associated GBS in the United States using a retrospective cohort design. We identified a cohort of patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of “intestinal infection due to Campylobacter” (008.43) using MarketScan Research Databases for 2004–2013. Campylobacterpatients with an encounter for “acute infective polyneuritis” (AIP; ICD-9-CM 357.0) were identified. Patients with an inpatient encounter having AIP as the principal diagnosis were considered probable GBS cases. Patients with probable GBS ≤8 weeks after the Campylobacterencounter were considered probable Campylobacter-associated GBS cases. For comparison, we repeated this analysis for patients with “other Salmonellainfections” (ICD-9-CM: 003). Among 9315 Campylobacterpatients, 16 met the case definition for probable GBS. Two were hospitalized with probable GBS ≤8 weeks after the encounter listing a Campylobacterdiagnosis (9 and 54 days) and were considered probable cases of Campylobacter-associated GBS; this results in an estimated cumulative incidence of 21.5 per 100,000 Campylobacterpatients (95% confidence interval [CI]: 3.7–86.6), or 5% of all estimated GBS cases. The remaining 14 patients were diagnosed with probable GBS on the same encounter (n= 12) or 1–3 days (n= 2), before the encounter listing the Campylobacterdiagnosis. Including these cases increased the cumulative incidence to 172 per 100,000 Campylobactercases (95% CI: 101.7–285.5), 41% of estimated GBS cases. This study, using a method not previously applied to United States data, supports other data that Campylobacteris an important contributor to GBS, accounting for at least 5% and possibly as many as 41% of all GBS cases. These data can be used to inform estimates of the burden of Campylobacterinfections, including economic cost.

Foodborne diseases present a major health problem in the United States in general, and transplant patients are at a higher risk from pathogens than the general population.

Many enteric pathogens disproportionately infect children. Hospital discharge data can provide information on severe infections, including cost. However, the diagnosis must be recorded on the discharge record and coded accurately. We estimated the rate of underascertainment in hospital discharge data among children with culture-confirmed Campylobacter, Salmonella, and Escherichia coliO157 infections using linked laboratory and hospital discharge data from an integrated health care organization. We reviewed the International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9/10-CM) diagnosis codes on each patient's discharge record. We determined the percentage of patients who had a pathogen-specific diagnosis code (for Campylobacter, Salmonella, or E. coliO157) or nonspecific gastroenteritis code. We included the first admission or positive test and calculated the number of days between specimen submission (outpatient ≤7 days before admission or inpatient) and hospital discharge. Of 65 hospitalized children with culture-confirmed Campylobacter(n= 30), Salmonella(n= 24), or E. coliO157 (n= 11) infections, 55% had that pathogen-specific diagnosis code listed on the discharge record (79% Salmonella, 54% E. coliO157, 37% Campylobacter). The discharge records of the 35 children with a specimen submitted for culture ≥3 days before discharge were 16 times more likely to have a pathogen-specific diagnosis than the records of the 30 children with a specimen submitted <3 days before discharge (83% vs. 23%; odds ratio 15.9, 95% confidence interval: 4.7–53.8). Overall, 34% of records of children with culture-confirmed infection had ≥1 nonspecific gastroenteritis code (Campylobacter43%, Salmonella29%, E. coliO157 18%), including 59% of those for children without a pathogen-specific diagnosis (Campylobacter63%; Salmonella60%; E. coliO157 40%). This study showed that hospital discharge data under-ascertain enteric illnesses in children even when the infections are culture confirmed, especially for infections that usually have a short length of stay.

AbstractDrug-resistant bacterial infections pose a serious and growing public health threat globally. In this review, we describe the role of the National Antimicrobial Resistance Monitoring System (NARMS) in providing data that help address the resistance problem and show how such a program can have broad positive impacts on public health. NARMS was formed two decades ago to help assess the consequences to human health arising from the use of antimicrobial drugs in food animal production in the United States. A collaboration among the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, the United States Department of Agriculture, and state and local health departments, NARMS uses an integrated “One Health” approach to monitor antimicrobial resistance in enteric bacteria from humans, retail meat, and food animals. NARMS has adapted to changing needs and threats by expanding surveillance catchment areas, examining new isolate sources, adding bacteria, adjusting sampling schemes, and modifying antimicrobial agents tested. NARMS data are not only essential for ensuring that antimicrobial drugs approved for food animals are used in ways that are safe for human health but they also help address broader food safety priorities. NARMS surveillance, applied research studies, and outbreak isolate testing provide data on the emergence of drug-resistant enteric bacteria; genetic mechanisms underlying resistance; movement of bacterial populations among humans, food, and food animals; and sources and outcomes of resistant and susceptible infections. These data can be used to guide and evaluate the impact of science-based policies, regulatory actions, antimicrobial stewardship initiatives, and other public health efforts aimed at preserving drug effectiveness, improving patient outcomes, and preventing infections. Many improvements have been made to NARMS over time and the program will continue to adapt to address emerging resistance threats, changes in clinical diagnostic practices, and new technologies, such as whole genome sequencing.

During September to October, 2006, state and local health departments and the Centers for Disease Control and Prevention investigated a large, multistate outbreak of Escherichia coliO157:H7 infections. Case patients were interviewed regarding specific foods consumed and other possible exposures. E. coliO157:H7 strains isolated from human and food specimens were subtyped using pulsed-field gel electrophoresis and multiple-locus variable-number tandem repeat analyses (MLVA). Two hundred twenty-five cases (191 confirmed and 34 probable) were identified in 27 states; 116 (56%) case patients were hospitalized, 39 (19%) developed hemolytic uremic syndrome, and 5 (2%) died. Among 176 case patients from whom E. coliO157:H7 with the outbreak genotype (MLVA outbreak strain) was isolated and who provided details regarding spinach exposure, 161 (91%) reported fresh spinach consumption during the 10 days before illness began. Among 116 patients who provided spinach brand information, 106 (91%) consumed bagged brand A. E. coliO157:H7 strains were isolated from 13 bags of brand A spinach collected from patients' homes; isolates from 12 bags had the same MLVA pattern. Comprehensive epidemiologic and laboratory investigations associated this large multistate outbreak of E. coliO157:H7 infections with consumption of fresh bagged spinach. MLVA, as a supplement to pulsed-field gel electrophoresis genotyping of case patient isolates, was important to discern outbreak-related cases. This outbreak resulted in enhanced federal and industry guidance to improve the safety of leafy green vegetables and launched an independent collaborative approach to produce safety research in 2007.

AbstractBackground:A growing segment of the population—adults aged ≥65 years—is more susceptible than younger adults to certain enteric (including foodborne) infections and experience more severe disease.Materials and Methods:Using data on laboratory-confirmed infections from the Foodborne Diseases Active Surveillance Network (FoodNet), we describe trends in the incidence of Campylobacterspp., Escherichia coliO157, Listeria monocytogenes, and nontyphoidal Salmonellainfections in adults aged ≥65 years over time and by age group and sex. We used data from FoodNet and other sources to estimate the total number of illnesses, hospitalizations, and deaths in the United States caused by these infections each year using a statistical model to adjust for underdiagnosis (taking into account medical care-seeking, stool sample submission, laboratory practices, and test sensitivity).Results:From 1996 to 2012, 4 pathogens caused 21,405 laboratory-confirmed infections among older adults residing in the FoodNet surveillance area; 49.3% were hospitalized, and 2.6% died. The average annual rate of infection was highest for Salmonella(12.8/100,000) and Campylobacter(12.1/100,000). Salmonellaand Listerialed as causes of death. Among older adults, rates of laboratory-confirmed infection and the percentage of patients who were hospitalized and who died generally increased with age. A notable exception was the rate of Campylobacterinfections, which decreased with increasing age. Adjusting for underdiagnosis, we estimated that these pathogens caused about 226,000 illnesses (≈600/100,000) annually among U.S. adults aged ≥65 years, resulting in≈9700 hospitalizations and ≈500 deaths.Conclusions:Campylobacter, E. coliO157, Listeria, and Salmonellaare major contributors to illness in older adults, highlighting the value of effective and targeted intervention.

AbstractBackground:Nontyphoidal Salmonellacauses an estimated 1.2 million infections, 23,000 hospitalizations, and 450 deaths annually in the United States. Most illnesses are self-limited; however, treatment with antimicrobial agents can be life-saving for invasive infections.Methods:The Foodborne Diseases Active Surveillance Network and the National Antimicrobial Resistance Monitoring System collaborated on a prospective cohort study of patients with nontyphoidal Salmonellabloodstream and gastrointestinal infections to determine differences in the clinical outcomes of resistant compared with pansusceptible infections. Interviews were conducted within 85 days of specimen collection date.Results:Of 875 nontyphoidal Salmonellaisolates, 705 (81%) were pansusceptible, 165 (19%) were resistant to at least 1 agent, and 5 (0.6%) had only intermediate resistance. The most common pattern, found in 51 (31%) of resistant isolates, was resistance to at least ampicillin, chloramphenicol, streptomycin, sulfisoxazole, and tetracycline (ACSSuT); 88% of isolates with this pattern were serotype Typhimurium or Newport. Fourteen (52%) of the 27 ceftriaxone-resistant isolates were also ACSSuT resistant. Adjusted for age and serotype, bloodstream infection was significantly more common among patients infected with strains resistant to only two, only three, or only five antimicrobial classes, to ACSSuT with or without other agents, to ACSSuT only, or to nalidixic acid with or without other agents than among patients with pansusceptible isolates. Adjusted for age, serotype, and bloodstream infection, hospitalization was significantly more common among patients infected with strains resistant to only three agents or to ceftriaxone (all ceftriaxone-resistant isolates were resistant to other agents) than among patients with pansusceptible isolates.Conclusion:This study extends evidence that patients with antimicrobial-resistant nontyphoidal Salmonellainfections have more severe outcomes. Prevention efforts are needed to reduce unnecessary antimicrobial use in patient care settings and in food animals to help prevent the emergence of resistance and infections with resistant nontyphoidal Salmonella.

Background: Escherichia coli O157:H7 infections have traditionally been associated with animal products, but outbreaks associated with produce have been reported with increasing frequency. In fall 1996, a small cluster of E. coli O157:H7 infections was epidemiologically linked to a particular brand (brand A) of unpasteurized apple juice. Objective: To define the extent of the outbreak, confirm the source, and determine how the apple juice became contaminated. Design: Descriptive epidemiologic study and traceback investigation. Setting: Western United States and British Columbia, Canada. Patients: Patients with E. coli O157:H7 infection who were exposed to brand A apple juice. Measurements: Clinical outcome and juice exposure histories of case-patients, pulsed-field gel electrophoresis of case and juice isolates, and juice production practices. Results: Seventy persons with E. coli O157:H7 infection and exposure to brand A unpasteurized apple juice were identified. Of these persons, 25 (36%) were hospitalized, 14 (20%) developed the hemolytic uremic syndrome, and 1 (1%) died. Recalled apple juice that was produced on 7 October 1996 grew E. coli O157:H7 with a pulsed-field gel electrophoresis pattern indistinguishable from that of case isolates. Apple juice produced on 7 October 1996 accounted for almost all of the cases, and the source of contamination was suspected to be incoming apples. Three lots of apples could explain contamination of the juice: Two lots originated from an orchard frequented by deer that were subsequently shown to carry E. coli O157: H7, and one lot contained decayed apples that had been waxed. Conclusions: Standard procedures at a state-of-the-art plant that produced unpasteurized juices were inadequate to eliminate contamination with E. coli O157:H7. This outbreak demonstrated that unpasteurized juices must be considered a potentially hazardous food and led to widespread changes in the fresh juice industry., Current techniques for producing unpasteurized apple juice may be inadequate to prevent transmission of pathogenic bacteria. Seventy people developed Escherichia coli O157:H7 infection after drinking a particular brand of juice. Twenty-five patients required hospitalization, 20% developed hemolytic uremic syndrome, and one patient died. All cases were traced to apple juice produced on Oct 7, 1996. Apples contaminated with deer feces or from a lot with decaying fruit accounted for transmission of the infectious bacteria. Unpasteurized juice should be regarded as potentially dangerous to health.

AbstractBackground:Shiga toxin–producing Escherichia coli(STEC) are an important cause of diarrhea and the major cause of postdiarrheal hemolytic uremic syndrome. Non-O157 STEC infections are being recognized with greater frequency because of changing laboratory practices.Methods:Foodborne Diseases Active Surveillance Network (FoodNet) site staff conducted active, population-based surveillance for laboratory-confirmed STEC infections. We assessed frequency and incidence of STEC infections by serogroup and examined and compared demographic factors, clinical characteristics, and frequency of international travel among patients.Results:During 2000–2010, FoodNet sites reported 2006 cases of non-O157 STEC infection and 5688 cases of O157 STEC infections. The number of reported non-O157 STEC infections increased from an incidence of 0.12 per 100,000 population in 2000 to 0.95 per 100,000 in 2010; while the rate of O157 STEC infections decreased from 2.17 to 0.95 per 100,000. Among non-O157 STEC, six serogroups were most commonly reported: O26 (26%), O103 (22%), O111 (19%), O121 (6%), O45 (5%), and O145 (4%). Non-O157 STEC infections were more common among Hispanics, and infections were less severe than those caused by O157 STEC, but this varied by serogroup. Fewer non-O157 STEC infections were associated with outbreaks (7% versus 20% for O157), while more were associated with international travel (14% versus 3% for O157).Conclusions:Improved understanding of the epidemiologic features of non-O157 STEC infections can inform food safety and other prevention efforts. To detect both O157 and non-O157 STEC infections, clinical laboratories should routinely and simultaneously test all stool specimens submitted for diagnosis of acute community-acquired diarrhea for O157 STEC and for Shiga toxin and ensure that isolates are sent to a public health laboratory for serotyping and subtyping.

AbstractBackground:Salmonellais a major bacterial pathogen transmitted commonly through food. Increasing resistance to antimicrobial agents (e.g., ceftriaxone, ciprofloxacin) used to treat serious Salmonellainfections threatens the utility of these agents. Infection with antimicrobial-resistant Salmonellahas been associated with increased risk of severe infection, hospitalization, and death. We describe changes in antimicrobial resistance among nontyphoidal Salmonellain the United States from 1996 through 2009.Methods:The Centers for Disease Control and Prevention's National Antimicrobial Resistance Monitoring System conducts surveillance of resistance among Salmonellaisolated from humans. From 1996 through 2009, public health laboratories submitted isolates for antimicrobial susceptibility testing. We used interpretive criteria from the Clinical and Laboratory Standards Institute and defined isolates with ciprofloxacin resistance or intermediate susceptibility as nonsusceptible to ciprofloxacin. Using logistic regression, we modeled annual data to assess changes in antimicrobial resistance.Results:From 1996 through 2009, the percentage of nontyphoidal Salmonellaisolates resistant to ceftriaxone increased from 0.2% to 3.4% (odds ratio [OR]=20, 95% confidence interval [CI] 6.3–64), and the percentage with nonsusceptibility to ciprofloxacin increased from 0.4% to 2.4% (OR=8.3, 95% CI 3.3–21). The percentage of isolates that were multidrug resistant (resistant to ≥3 antimicrobial classes) decreased from 17% to 9.6% (OR=0.6, 95% CI 0.5–0.7), which was driven mainly by a decline among serotype Typhimurium. However, multidrug resistance increased from 5.9% in 1996 to a peak of 31% in 2001 among serotype Newport and increased from 12% in 1996 to 26% in 2009 (OR=2.6, 95% CI 1.1–6.2) among serotype Heidelberg.Conclusions:We describe an increase in resistance to ceftriaxone and nonsusceptibility to ciprofloxacin and an overall decline in multidrug resistance. Trends varied by serotype. Because of evidence that antimicrobial resistance among Salmonellais predominantly a consequence of antimicrobial use in food animals, efforts are needed to reduce unnecessary use, especially of critically important agents.

Many enteric pathogens disproportionately affect young children. However, higher incidences of laboratory-confirmed illness may be explained, at least in part, by higher rates of medical care-seeking and stool sample submission in this age group. We estimated the overall number of bacterial enteric illnesses among children <5 years old in the United States caused by Campylobacter, Escherichia coliO157, nontyphoidal Salmonella, Shigellaand Yersinia enterocolitica.

OBJECTIVE To describe pathogens identified through routine clinical practice and factors associated with identifying Shiga toxin–producing Escherichia coli (STEC) infection in patients with postdiarrheal hemolytic uremic syndrome (D+HUS). DESIGN Population-based active surveillance. SETTING Hospitals in the FoodNet surveillance areas from 2000 through 2010. PARTICIPANTS Children younger than 18 years with D+HUS. MAIN EXPOSURES Testing for STEC and demographic and clinical characteristics. MAIN OUTCOME MEASURES Percentage of patients with evidence of infection with likely HUS-causing agents and associations between exposures and evidence of STEC infection. RESULTS Of 617 patients, 436 (70.7%) had evidence of infection with likely HUS-causing agents: STEC O157 (401 patients), non-O157 STEC (21 patients), O157 and non-O157 STEC (1 patient), Streptococcus pneumoniae (11 patients), and other pathogens (2 patients). Among patients without microbiological evidence of STEC, 76.9% of those tested had serologic evidence of STEC infection. Children more likely to have evidence of STEC infections included those patients tested for STEC less than 4 days after diarrhea onset, 12 months or older (71.6% vs 27.8% if &lt;12 months of age), with infections as part of an outbreak (94.3% vs 67.3%), with bloody diarrhea (77.2% vs 40.4%), with onset during June through September (76.9% vs 60.1%), with a leukocyte count greater than 18 000/μL (to convert to ×109/L, multiply by 0.001) (75.7% vs 65.3%), or with only moderate anemia (hemoglobin >7.0 g/dL [to convert to grams per liter, multiply by 10] or hematocrit greater than 20% [to convert to a proportion of 1, multiply by 0.01]) (75.1% vs 66.3%). However, many of these associations were weaker among children with thorough STEC testing. CONCLUSIONS Early stool collection for E coli O157 culture and Shiga toxin testing of all children with possible bacterial enteric infection will increase detection of STEC strains causing HUS. In the absence of microbiological evidence of STEC, serologic testing should be performed.

AbstractClinical laboratory practices affect patient care and disease surveillance. It is recommended that laboratories routinely use both culture for Escherichia coliO157 and a method that detects Shiga toxins (Stx) to identify all Stx-producing E. coli(STEC) and that labs send broths or isolates to a public health laboratory. In 2007, we surveyed laboratories serving Foodborne Diseases Active Surveillance Network sites that performed on-site enteric disease diagnostic testing to determine their culture and nonculture-based testing practices for STEC identification. Our goals were to measure changes over time in laboratory practices and to compare reported practices with published recommendations. Overall, 89% of laboratories used only culture-based methods, 7% used only Stx enzyme immunoassay (EIA), and 4% used both Stx EIA and culture-based methods. Only 2% of laboratories reported simultaneous culture for O157 STEC and use of Stx EIA. The proportion that ever used Stx EIA increased from 6% in 2003 to 11% in 2007. The proportion that routinely tested all specimens with at least one method was 66% in 2003 versus 71% in 2007. Reference laboratories were less likely than others to test all specimens routinely by one or more of these methods (48% vs. 73%, p= 0.03). As of 2007, most laboratories complied with recommendations for O157 STEC testing by culture but not with recommendations for detection of non-O157 STEC. The proportion of laboratories that culture stools for O157 STEC has changed little since 2003, whereas testing for Stx has increased.

Human outbreaks of Salmonellainfection have been attributed to a variety of food vehicles. Processed snack foods are increasingly consumed by children. In May 2007, state and local health departments and the Centers for Disease Control and Prevention investigated human infections from SalmonellaWandsworth, an extremely rare serotype.

AbstractBackground:To better understand the sources of foodborne illness, we propose a scheme for categorizing foods implicated in investigations of outbreaks of foodborne diseases. Because nearly 2000 foods have been reported as causing outbreaks in the United States, foods must be grouped for meaningful analyses.Methods:We defined a hierarchy of 17 mutually exclusive food commodities. We defined the following three commodity groups from which nearly all food is derived: aquatic animals, land animals, and plants. We defined three commodities in aquatic animals, six in land animals, and eight in plants. We considered each food as a set of ingredients composed of one or more commodities. We defined a simple food as one made of ingredients that are all in one commodity and a complex food as one containing ingredients in more than one commodity. We determined likely ingredients using a panel of epidemiologists and a web-based search process.Results:We assigned 1709 (95%) of the 1794 foods implicated in outbreaks of foodborne diseases reported to Centers for Disease Control and Prevention from 1973 to 2006. Of those, 987 (57%) were simple foods and 722 (43%) were complex foods.Discussion:This categorization may serve as an input for modeling the attribution of human illness to specific food commodities and could be used by policy makers, health officials, regulatory agencies, and consumer groups to evaluate the contribution of various food commodities to illness.

The article offers a guide to planning a green meeting. It presents a Meeting Planner Questionnaire from the Green Hotels Association which is designed for those who want to have green events to fax the form to hotels to get responses about how green their events can be at each site, and for hotels and meeting venues to be proactive by keeping the form updated. Asking the attendees to participate in the green program is advised, as well as collecting recyclables.

We examined the efficacy of recall notification and advertising in informing the public about a nationwide recall of hot dogs and deli meats. As part of an ongoing random population telephone survey, residents of seven states were interviewed. Data from the survey were weighted to account for the multistage sampling design. Overall, 307 (45%) of 633 knew about the recall. Knowledge was higher among persons older than 40 years (odds ratio = 2.1, 95% confidence interval = 1.4 to 3.3) and persons interviewed after major newspaper notices about the recall. Among those who knew about the recall, 5% believed the products were safe to eat; 23% were not sure. Seventy percent learned about the recall through television. Our findings indicate that routine recall notifications failed to reach a large portion of the population and were not well understood. Messages to the public about recalled products should clearly describe the risks of consuming the recalled product. Supplemental advertising by manufacturers can be beneficial if the risks of consuming the recalled product and recommendations to consumers are clearly described. These policies, coupled with broader distribution through the television and print media, may help increase the proportion of the persons who receive the information they need from future product recalls.

From October 1997 through March 1998, three outbreaks of gastrointestinal illness among school children were linked to company A burritos. In September 1998, a similar outbreak occurred in three North Dakota schools following lunches that included company B burritos. We conducted an investigation to determine the source of the North Dakota outbreak, identify other similar outbreaks, characterize the illness, and gather evidence about the cause. The investigation included epidemiologic analyses, environmental investigation, and laboratory analyses. In North Dakota, a case was defined as nausea, headache, abdominal cramps, vomiting, or diarrhea after lunch on 16 September 1998. Case definitions varied in the other states. In North Dakota, 504 students and staff met the case definition; predominant symptoms were nausea (72%), headache (68%), abdominal cramps (54%), vomiting (24%), and diarrhea (16%). The median incubation period was 35 min and median duration of illness was 6 h. Eating burritos was significantly associated with illness (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.2). We identified 16 outbreaks that occurred in seven states from October 1997 through October 1998, affecting more than 1,900 people who ate burritos from two unrelated companies. All tortillas were made with wheat flour, but the fillings differed, suggesting that tortillas contained the etiologic agent. Results of plant inspections, tracebacks, and laboratory investigations were unrevealing. More than two million pounds of burritos were recalled or held from distribution. The short incubation period, symptoms, and laboratory data suggest that these outbreaks were caused by an undetected toxin or an agent not previously associated with this clinical syndrome. Mass psychogenic illness is an unlikely explanation because of the large number of sites where outbreaks occurred over a short period, the similarity of symptoms, the common food item, the lack of publicity, and the link to only two companies. A network of laboratories that can rapidly identify known and screen for unknown agents in food is a critical part of protecting the food supply against natural and intentional contamination.

The objective of this study was to describe the epidemiology of foodborne disease outbreaks in schools and to identify where preventive measures could be targeted.

The U.S. food supply is characterized increasingly by centralized production and wide distribution of products, and more foodborne disease outbreaks are dispersed over broad geographic areas. Such outbreaks may present as a gradual, diffuse, and initially unapparent increase in sporadic cases. Recognition and reporting by clinicians and local public health officials and the ordering of laboratory tests by clinicians continue to be cornerstones of detecting all outbreaks. New methods—such as active laboratory-based surveillance, automated algorithms for detecting increases in infection rates, and molecular subtyping—facilitate detection of diffuse outbreaks. Routines have evolved for the investigation of multistate outbreaks; they are characterized by rapid communication between local, state, and federal public health officials; timely review of epidemiologic data by expert panels; collaboration on tracebacks with food safety regulatory agencies; and communication with the public and media. Rapid, efficient investigation of multistate outbreaks may result in control of acute public health emergencies, identification and correction of hazardous food production and processing practices, and consequent improvement in food safety.

ABSTRACTNon-cholera Vibrioinfections are an important public health problem. Non-cholera Vibriospecies usually cause sporadic infections, often in coastal states, and have also caused several recent nationwide outbreaks of gastroenteritis in the United States. We report a survey of laboratory stool culturing practices forVibrioamong randomly selected clinical laboratories in Gulf Coast states (Alabama, Florida, Louisiana, Mississippi, and Texas). Interviews conducted with the microbiology supervisors of 201 clinical laboratories found that 164 (82%) received stool specimens for culture. Of these, 102 (62%) of 164 processed stool specimens on site, and 20 (20%) of these 102 laboratories cultured all stool specimens for Vibrio, indicating that at least 34,463 (22%) of 152,797 stool specimens were cultured for Vibrio. This survey suggests that despite an increased incidence of non-choleraVibrioinfections in Gulf Coast states, a low percentage of clinical laboratories routinely screen all stool specimens, and fewer than 25% of stool specimens collected are routinely screened for non-cholera Vibrio.

Shiga-like toxin-producingEscherichia coli O157:H7 are important causes of bloody diarrhea and hemolytic uremic syndrome. To facilitate the epidemiologic study of these organisms, we developed enzyme-linked immunosorbent assays (ELISAs) for antibodies to Shiga-like toxin I (SLT I), Shiga-like toxin II (SLT II), andE. coli O157 lipopolysaccharide (LPS). We tested serum samples from 83 patients in two outbreaks ofE. coli O157:H7 diarrhea and from 66 well persons. Forty-three patients (52%) had at least one serum sample positive for anti-O157 LPS antibodies; among 26 culture-confirmed patients, 24 (92%) had at least one positive serum sample. Two (3%) of 66 control sera had positive anti-O157 LPS titers. ELISA results for SLT I and II were compared with those of HeLa cell cytotoxicity neutralization assays on both patient and control sera. Neutralization assays detected anti-SLT I antibodies in at least one serum sample from each of 17 (20%) patients and 7 (10.6%) controls, while 16 (19%) patients and 7 controls had positive titers by anti-SLT I ELISA. Although all serum samples, including control sera, showed nonspecific neutralization of SLT II, no antibody titers to SLT II were detected by either neutralization or ELISA. These results indicate that ELISAs for SLT I and SLT II antibodies are comparable to HeLa cell cytotoxicity neutralization assays. Both the ELISAs and neutralization assays are insensitive in detecting infected patients. However, the ELISA for antibodies toE. coli O157 LPS is both sensitive and specific, and may be more useful than assays for antitoxic antibodies in detecting persons withE. coli O157:H7 infection.

Objective:In January 1996, an outbreak of diarrhea caused by SalmonellaEnteritidis occurred in children attending a Komodo dragon exhibit at a metropolitan zoo. We sought to determine the extent of the outbreak and mode of transmission. Study design:A case-control study was conducted. Controls were randomly selected from zoo membership lists and matched to patients by age group and date of exhibit visit. Results:Of 65 patients identified, 39 had confirmed and 26 had suspected cases. The median age was 7 years (range, 3 months to 48 years); 55% were male, and 56% had bloody diarrhea. Twenty-six patients and 49 controls were enrolled in the case-control study. No patients and two (4%) controls reported touching a dragon; however, 83% of patients but only 52% of controls touched the wooden barrier that surrounded the dragon pen (odds ratio = 4.0, 95% CI 1.2 to 13.9). Washing hands at the zoo after visiting the dragons was highly protective (OR = 0.14, 95% CI 0.03 to 0.7). Cultures from the patients, one dragon, and the exhibit barriers yielded SalmonellaEnteritidis, phage type 8. On the basis of an attack rate of 4.3% among exhibit attendees under 13 years old on whom data were collected, we estimate that 315 additional cases of salmonellosis occurred among visitors in this age group. Conclusion:This large outbreak demonstrates the importance of environmental contamination in the transmission of Salmonellafrom reptiles, and the protective value of hand washing. Recommendations regarding reptile exhibits and reptilian pets should emphasize this indirect route. (J Pediatr 1998;132:802-7)

Data collected by nine population-based tumor registries participating in the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute were analyzed to characterize the epidemiology of noncarcinoid adenocarcinomas of the colon and rectum in young adults. Tumors diagnosed in persons under 40 years old between 1973 and 1984 (n = 1736) were compared with those in persons 40 years and older (n = 106,760). This first large U.S. population-based study of colorectal adenocarcinomas in the young shows a higher incidence in blacks than whites and later detection in black males. It also shows a higher proportion of tumors of mucinous and signet ring histological type than in older age groups. Among the younger group, the average annual age-adjusted incidence rate was 34% higher in black males than in white males (12.6 vs. 9.4 per million persons) and 46% higher in black females than in white females (13.0 vs. 8.9 per million persons). The proportion of tumors that were right-sided varied by age: 0–29 years, 30%; 30–39 years, 26%; 40–49 years, 22%; 50–59 years, 21%; 60–69 years, 24%; 70–79 years, 30%; and 80+ years, 35%. Males under age 40 were less likely to present with localized disease (whites, 27%; blacks, 21%) than were those aged 40 and older (whites, 39%; blacks, 36%). The proportion of tumors classified as mucinous decreased with age, from 28% among those aged 0–19 years to 5% among those 40 years and older. A similar trend was observed for signet ring tumors. Although this latter type accounted for 10% of large-bowel tumors among subjects aged 0–19 years, this proportion decreased with age to 0.2% in those 40 years and older.

This research determined the alcoholism-related and other correlates of the discrepancy between life expectancy in females and males using information for 161 different countries. The variables that correlated most highly with female minus male life expectancy were per capita alcohol consumption, cirrhosis of the liver deaths per capita, and overall life expectancy. Greater gender discrepancy was also found in non-Moslem countries and in countries with greater per capita income and less infant mortality. Public health implications are discussed.

Diarrhea and weight loss are common features of pediatric and adult human immunodeficiency type 1 HIV1 infection, particularly in developing countries. We studied prospectively episodes of diarrhea in 559 children, ages 10 to 15 months, participating in a longitudinal study of perinatal HIV1 infection in Kinshasa, Zaire. Children with HIV1 infection had more frequent episodes of diarrhea and were more likely to present with fever or moderate or severe dehydration and to have persistent or fatal diarrhea. Of 9 HIV 1positive infants with diarrhea, 3 had enteroadherence factorpositiveEscherichia coli, compared with 5 of 74 HIV 1 negative children with diarrhea P0.04 no other pathogen was associated with HIV1 infection. In a logistic regression model diarrhea was significantly associated with HIV1 infection in the child, moderate or severe malnutrition and symptoms of acquired immunodeficiency syndrome in the mother. Diarhea among children with perinatal HIV infection in Zaire is more severe than among uninfected children and is associated with malnutrition and advanced disease in the mother.

Abstract

Hemorrhagic colitis is characterized by abdominal cramps, bloody diarrhea, and no or low-grade fever. Most cases are caused by the Shiga-like toxin-producing bacteria, Escherichia coli0157:H7. Nineteen colonic biopsy specimens and one resection specimen were reviewed from 11 patients with E. coli0157:H7-associated colitis to determine whether histologic features could be useful in diagnosis or in suggesting pathogenesis. All specimens showed hemorrhage and edema in the lamina propria. Specimens from nine patients were focally necrotic and showed hemorrhage and acute inflammation in the superficial mucosa with preservation of the deep crypts, similar to the pattern of injury associated with acute ischemic colitis. Specimens from five patients showed neutrophils focally infiltrating the lamina propria and crypts, resembling the pattern of injury seen in infectious colitis. One or both of these histologic patterns were observed in specimens from all but one patient. Specimens from four patients had poorly formed inflammatory pseudomembranes. It is concluded that the histologic features of E. coli0157:H7-associated colitis resemble a combination of ischemic and infectious injuries similar to those described in toxin-mediated Clostridium difficile-associated colitis. This suggests that the toxin(s) produced by these E. coliplay a role in the colonic injury. Infection with E. coli0157:H7 should be considered in the differential diagnosis of ischemic and infectious colitis.

We present a computationally simple and inexpensive method to induce coincidence between one map and another, regardless of their respective projections. We imagine the map to be transformed on a rubber sheet stretched to coincide with a stable base map at an average of 15 control points; for more precise coincidence, we add more control points. We compute triangles on the rubber-sheet map, using control points as vertices, and with a procedure called piecewise linear homeomorphism, map these triangles linearly onto corresponding triangles on the stable map.

Monitored treatment in the community, also known as conditional release, has been described as the most important advance in the treatment of insanity acquittees in the last decade. Despite the importance of the development of conditional release, however, there has been relatively little written about relevant issues and planning principles important in designing and implementing conditional release systems. The present paper discusses important considerations relevant to conditional release that are associated with key decision points within systems for persons found not guilty by reason of insanity (NGRI). Four planning principles, generalizable to all NGRI systems, are then presented in a way that integrates the previous discussion. It is concluded that conditional release plays a crucial role in the treatment of insanity acquittees and that mental health administrators may either proactively modify their systems, in a way that balances public safety with individual rights and treatment needs, or wait for the modification mandate to be forced upon them in the wake of a highly publicized, heinous offense.

To describe a family cluster of Shiga toxin-producing Escherichia coliO111:NM infection.